Cathy GrahameAmbulatory Care Manager at John Hunter Children's hospital in NewcastleToday I am going to discuss our approach to the redevelopment of our paediatric outpatients services and our achievements so far
It is best to start by describing the problem:Feedback from the 2008 NSW Health Paediatric satisfaction report regarding how the public viewed the organisation of the paediatric clinics. Patient satisfaction was at 60%.GPs were frustrated not knowing what had happened to their patients referrals and were frequently confused as to who they should refer to, often putting every Doctors name they could think of at the top of the referral.Business was increasing, both demand and through increased delivery of new tertiary services not previously offered by the Childrens Hospital in NewcastleIt was the poor cousin, run traditionally as an afterthought to in-patient services. Run by a group of busy clinicians with competing agendas.The department through necessity was running itself Finally it was time for Outpatients services to have an overhaul
Before we get into talking about the program I’d like to take moment to recognise the dedication of our team to improving services for our patients and their families and I’d like to personally thank all of them for their hard work.
So in 2009 we started ourformal ambulatory care program and our objective was to develop a child and family centred service model by Developing an Ambulatory care strategyImprove patient and family satisfaction by improving management, coordination and communication for children and families that use these servicesConsidering scheduling and clinic functionality: that is how clinic space is allocated, how clinic sessions were organised and how are decisions madeImproving Referral management: how referrals enter the service/how we track them through the triage and booking processStreamlining clinic bookings: who gets priority, how do we accommodate multidisc clinics, how do we configure our sessions to get maximum benefit, what templates look like
Clinic overview in 200912 clinic rooms for all specialties, 2 rooms offsite 15 minutes away>40 specialists5.4 staff for both admin and nursingNo designated manager or a team to provide leadership and as a consequence there was poor decision making
This is a retrospective performance snapshot of 2009/2010. I draw your attention to: the DNA figure the proportion of new to follow-up ANDThe excessive waiting time for some familiesThis information was not reported on regularly nor at any formal committee
Current clinic waiting roomLooks nice but remember nearly 20,000 people annually (sometimes 150 children per day) had to sit down on these 20 chairs
I would like to take a moment with this slide to show you what the consultation uncoveredIt captured all of the issues and is perhaps not unexpectedly complex!We found this information by consulting with internal and external stakeholders: staff, families & GP’s through surveys, focus groups & interviews.Then we mapped the issues into two sections: those related to strategy (that is, what supported & governed the process) and processes themselves.
There were a number of key solutions in both the strategy section & the process section and I am going to talk about these in a little more detail.
Strategy 1LeadershipLeadership was identified as a major factor in the success of the service.Current roles were reviewed including most importantly the Ambulatory Care management and the senior clerical coordinator and how these roles interfacedGovernanceHow the ambulatory care service should sit within the governance structure of the CHHow the management of these services should be developed especially with a more strategic focus in particular reviewing membership / terms of reference / accountabilities of the JHCH Ambulatory Care Management Committee
The second strategy was the formation of a Professional Users Guide that provides leaders & clinicians with a guide on how the clinic functions.Information such as:How to organise a provider Number how to book clinic roomsBilling options how to set up your template to work alongside a registrarHow to set up and apply for a new clinicThis consistent information assists the management team in making structured impartial decisions on day to day matters.It also makes a very good orientation tool.
The third strategy was to develop a service framework that describes and communicates to all health professionals.So this involved information such as Individual specialty service descriptionsReferral requirements / criteria The service provider – so who are the clinicians currently providing the service What was the services core business Service alternatives when referrals didn’t meet intake criteria. Eg headaches often not accepted into Neurology specialty.This information is now available on both Kaleidoscope & Health Pathways websites and now I am going to show you an example
This is an example of the Kaleidoscope website & the sort of information it provides for exampleName of specialty (point to this)Referral criteriaAverage waiting time
When you drill down this example is allergy/immunology, it contains things as the service description/referral requirements and links to other information such as referral forms.
Strategy 4This is really about the timetable – Who goes where?When & how well are those clinics run?What services are offered by which clinicians?And what time should they open and close
This is the first of two slides.In 2009 this was the map of referrals into our service:How did they enter?Who touched them?Where the decisions were made?Remember there was no electronic system for referrals, they often went directly to the specialist.So variation; duplication and referral failure were common practice.And here you can see examples of how this affected the families.Lisa and Lilly said…”Wait times to see a Dr anywhere in the hospital is horrendous”Kate and Tom - “I had to wait an hour and a half for my appointment …That was the only thing that disappointed me on the day”
This is what we do now.Referring GP or service, accesses service information on the internet at www.kaleidoscope.org or via healthpathways. The Information includes service description, referral criteria (what conditions they do and don’t accept), and how to refer for each specialty service.GP faxes referral for the child’s appointment. JHCH RIMS: referral received via fax / converted to PDF checked for accuracy referral forwarded to nominated clinician for triage If family contacts the service we are able to inform them of where there referral is up to with processing 100% trackingTriage processes:The clinician views and triages the referral via RIMSThe clinician assigns a triage category code that informs the waitlist and booking processes We are basing our traige categories on the surgical triage which is within 7days/30days/90days/365DaysWaitlist & Booking processes:Administrative staff member will either waitlist or book an appointment for the child based on triage category code and any additional information provided by the clinician. Family receives notification of appointment status via mail.GP sent notification that referral has been received and under reviewFamily receives SMS message as a reminder 3 days prior to their appointment.
You may have heard me mention Health Pathways. I’m only going to touch on this briefly as it is a whole presentation in itself. This new initiative has grown out of the Kaleidoscope Ambulatory Care program. It is an online health information portal, resulting from a partnership with HNE LHD, the Medicare Local, and the NZ Canterbury Initiative. It covers all patients and is aimed at GP’s. It provides information on how to assess, manage and refer patients to local specialists.We are currently using health pathways to help manage some of the longer waitlists, referring GPs to the site if the specialists feel that a condition could be managed in primary care with support of health pathways which saves appointments for more urgent cases.
This is an example of our recently localised Paediatric UTI PathwayThe flow of each pathway allows: - GPs and other referrers ability to search for a condition using key words - Information on assessment and management “Red flags” alert referrers to important things - And “practice points” give management tips that save time - There’s clear advice on when/how to refer to specialist services - - The HealthPathways site helps referrers at the point of care
Are there some challenges? Of courseFor us these are increased workload, communication of changes, managing waitlists, physical space keeping within 12 rooms, and schedule management such as planning annual leave.
Did this make a difference? We have increased by 6.3% the number of children attending.We reduced DNA rates 12.2% to 10.17% equates to a further 20% utilisation improvement.11 Health Care Pathways are either fully functional or near completedManager available to respond to referrers which improved performance and decreased frustration
This slide shows that we have agreed and monitored KPI’s that demonstratethe increase in attendance.The number of apptscancelledThe number of apptsrescheduled the number of families that did not attendThis assures us that our performance remains on track.
Did something else good happen?We got support for a rebuild that will be completed in 2013.Although our current area looked nice we now have the opportunity to:Improve patient flows, Currently our respiratory Lab is across the hall in a different department and within our rebuild this will be moved within the department.Our current height and weight station is at the furthest point from the waiting room, this will now be moved straight off the waiting roomThe clinic rooms will be sectioned off so the public and unauthorised staff will not have access to wonder through the department disrupting clinics giving families and clinicians privacy during consults.
Cathy Grahame - Kaleidoscope Ambulatory Care Program - More than just a clinic
Kaleidoscope AmbulatoryCare ProgramMore than just a clinicTuesday 23 October 2012
The Problem• Satisfaction from families was at 60%, evidenced by the NSW Health Paediatric Statewide report, 2008• Complaints from General Practitioners were frequent• Demand for clinic space and appointments were increasing• Poor cousin to inpatient services
Kaleidoscope Ambulatory Care ProgramAugust 2009Objective: to develop a child andfamily centred service model by: – Ambulatory Care Strategy – Improving patient and family satisfaction – Clinic Scheduling & Functionality – Referral Management – Clinic Bookings
John Hunter Childrens Hospital Clinic overview 2009• 12 clinic rooms for all disciplines and specialties - 2 of those 12 clinic rooms off site (15 minutes away)• Over 40 specialists holding clinics• Shared NUM with inpatient unit• 5.4 staff (admin/nursing)• No designated manager/leadership team
Clinic StatisticsPerformance Snapshot: 2009 - 2010 Total number of patients booked 18 648 % of appointments attended 82% % of Did Not Attends (DNA) 12.2% % Cancellations 4.0% % Appointments rescheduled 27% % of new patients 29% % of follow up patients 71% Minimum wait for first appointment 2 weeks Maximum wait for first appointment 20 months
Strategy (1): Leadership & GovernanceLeadership: • The allocation of a designated leader / manager • Clarity of clinical and non-clinical leadership roles, responsibilities, and accountabilitiesGovernance: review & modification of: • Current governance structures • membership / terms of reference / accountabilities of the JHCH Ambulatory Care Management Committee
Strategy (2): Operational Guidelines• To provide leaders and clinicians with a guide to assist in making informed & impartial operational decisions on clinic functionality• As an orientation / information tool for HNEAHS clinicians
Strategy (3): Service FrameworkPurpose: describes and communicates to health professionals: • Individual specialty service • Referral requirements / criteria • The service provider • Core service business • Service alternatives
Strategy (4): Schedule Management• Review clinic utilisation and specialty demand• Consider the current models of care• Investigate the feasibility of changing the clinic opening & closing times.
Processes (1): 2009 Referral / Booking / WaitlistProcess Map of referral management and bookings process 2009
Processes (2): Referral / Booking / Waitlist in 2012Referring GP / The clinician views the referral &service faxes assigns a triage category code:referral to 7Days/30days/90Days/365Days.central Intake Referrals In Paediatric Ambulatory Care John Hunter Childrens Hospital General Practitioner Primary / Community Care Emergency Emergency Telephone Care Department Advice Staff / VMO Specialists Triage Allocation of Appointment Assessment in Clinic Rural / District Referral Hospital Allied Health • Booking according to triage code. ’ RIMS = Referral • Family & GP notified. Information Management • SMS reminder 3 System: days prior. • family notification • Clinic planning • 100% tracking
Challenges• Increased workload for administration staff with RIMS process (RIMS = Referral information Management System)• Communication to the 40 different clinicians and changes in practice with referral management.• Waitlist management• Physical space.• Schedule management.
Achievements so far• Full time Ambulatory Care Manager• Ambulatory Care Management Committee• Professional Users Guide for Ambulatory Care• Website for GP’s• Fully electronic referral management system• Structured bookings and waitlist• SMS message reminders for appointments• Identified KPI’s monitored monthly• Health Pathways
Performance 2012• Improved efficiency: 6.3% pa• 100% tracking of referrals• Reduced DNA rates 12.2% (2009) to 10.17% (2012) even with an increase in patients seen, a 20% improvement.• 7 paediatric healthcare pathways completed and 4 currently under development• Manager
Identification and monitoring:Paediatric Ambulatory care KPI’s